Care processes and outcomes of deprivation across the clinical course of kidney disease: findings from a high-income country with universal healthcare

Abstract

Background: No single study contrasts the extent and consequences of inequity of kidney care across the clinical course of kidney disease.

Methods: This population study of Grampian (UK) followed incident presentations of acute kidney injury (AKI) and incident estimated glomerular filtration rate (eGFR) thresholds of <60, <45 and <30 mL/min/1.73 m2 in separate cohorts (2011-2021). The key exposure was area-level deprivation (lowest quintile of the Scottish Index of Multiple Deprivation). Outcomes were care processes (monitoring, prescribing, appointments, unscheduled care), long-term mortality and kidney failure. Modelling involved multivariable logistic regression, negative binomial regression and cause-specific Cox models with and without adjustment of comorbidities.

Results: There were 41 313, 51 190, 32 171 and 17 781 new presentations of AKI and eGFR thresholds <60, <45 and <30 mL/min/1.73 m2. A total of 6.1-7.8% of the population was from deprived areas and (versus all others) presented on average 5 years younger, with more diabetes and pulmonary and liver disease. Those from deprived areas were more likely to present initially in hospital, less likely to receive community monitoring, less likely to attend appointments and more likely to have an unplanned emergency department or hospital admission episode. Deprivation had the greatest association with long-term kidney failure at the eGFR <60 mL/min/1.73 m2 threshold {adjusted hazard ratio [HR] 1.48 [95% confidence interval (CI) 1.17-1.87]} and this association decreased with advancing disease severity [HR 1.09 (95% CI 0.93-1.28) at eGFR <30 mL/min/1.73 m2), with a similar pattern for mortality. Across all analyses the most detrimental associations of deprivation were an eGFR threshold <60 mL/min/1.73 m2, AKI, males and those <65 years of age.

Conclusions: Even in a high-income country with universal healthcare, serious and consistent inequities in kidney care exist. The poorer care and outcomes with area-level deprivation were greater earlier in the disease course.

Keywords: AKI; CKD; care processes; epidemiology; health inequalities; prognosis.

Graphical Abstract

FIGURE 1:

Logic model of assumptions for the bidirectional relationships between kidney disease clinical course, comorbidities and socio-economic factors.

FIGURE 2:

Age- and sex-standardised 1-year mortality risk of people with new-onset (A) eGFR <60 ml/min/1.73 m², (B) eGFR <45  ml/min/1.73 m² and (C) eGFR <30  ml/min/1.73 m² grouped by localities of deprivation (red ``+''), affluence (blue ``I''), and all other areas (yellow ``o'').